Epilepsy and Pregnancy
Epilepsy and Pregnancy
Epilepsy and Pregnancy
Vincenzo Lanza
Servizio di Anestesia e Rianimazione Ospedale Buccheri La Ferla FATEBENEFRATELLI
E.MAIL. [email protected]
Epilepsy is a disease presenting with different kinds of symptoms going from the generalized seizures
to an impairment of consciousness of a few seconds.
In pregnancy , the most important clinical presentation for the anesthetist is the epilepsy with
convulsive symptoms.
1.1 Etiology
Epilepsy is a disorder affecting 2% of population when in association with other encefalopathic form
and about 0.5% referring with the simple disease.The latter concerns with subjects with normal
coefficient intellective without any other mental problem except for the psychological one. In the
anamnesis of these patients is often possible to find high temperature the first time convulsive disorders
appear while temperature disappearing in the following episodes. Generally "febrile seizures" are
considered normal until the age of 6 years because of immaturity of cerebral structures, but they are
considered as epileptic disease after the age of 6 years . A differential diagnosis can be made with the
EEG : subjects with a pathological EEG without fever surely will have in puberty epilepsy also without
clinical crisis.Different features of epilepsy (absence seizures, convulsive seizures etc.) can coexist or
replace one another in the same patient. In tab.1 the International Classification of Epileptic Seizures is
shown.
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2. Epilepsy in pregnancy
We can find very few reports (50/100.000 pregnant women) of patients with no previous
history of epilepsy that present the appearance of a chronic epileptic disease during
pregnancy.
Several statistics point out an increase of epileptic crisis frequency. The incidence ranges
from 40 to 50%. The causes have to be investigated in the physiological changes of
pregnancy:
* Reduction of functional residual capacity with hypocapnia and possible reduction of cerebral
flow.
*The typical "nitrogen sparing" of pregnant woman with consequent change of the amino
acids pattern.
*The increased metabolism and excretion of hidantoyn (100% more) that may reduce plasma
concentration to subtherapeutic levels.
The epileptic patient shows a greater incidence of neonatal disease. This is likely to be due to
toxic effects of anticonvulsant drugs [3] and to epileptic seizures.
6-10% of epileptic patients in pregnancy shows tonic-clonic seizures. During the seizures, a
trauma to mother and fetus, abruptio placental, fetal intra-cranial hemorrhage, miscarriage,
fetal neonatal and prenatal death may occur.
Treatment of epilepsy often consists of more than one drug administration to prevent the toxic
effects of a drug alone. The side-effects of these drugs are often unacceptable in pregnancy,
but discontinuation of one or more drugs as well as the physiologic and metabolic changes
associated with pregnancy, can trigger a cluster of seizures that can lead to a dangerous
status epilepticus.
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* Fetal malformation of the fingers and face occurs in 5-30% up to 40% in untreated patients.
These malformations are more frequent in epileptic patients who lack of folates.
* The treatment with valproic acid may produce an increased incidence (1%) of neural tube
defects as spina bifida aperta that raises up to 5% during carbamazepine treatment.
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- Pre-eclampsia
In these patients seizures often occur during labor, thus representing a relevant therapeutic
problem; differential diagnosis should consider brain tumor . We observed 40 y patient,
hospitalized for a bigeminal pregnancy, who developed seizures because of brain
tuberculosis. Pre-eclampsia incidence in our hospital and patient outcome are shown in tab.3
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Patients already known as epileptic do not present problems for diagnosis. Instead, diagnosis
can be difficult in patients suffering from absences, often hidden for shame, who develop
generalized seizures. Therefore patients who do not have epileptic disease but present risk
factors represent the more problematic group. These patients often begin a single seizure and
then quickly organize an epilepticus status. In our experience on about 16000 deliveries, just
one patient with these characteristics has occurred.
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To avoid toxic risks shown in the point 2.3.2. ,epilepsy treatment with more than one drug has
to be stopped. Phenytoin is the drug more commonly used alone. The drug already used by
patient should be preferred. The switch to an alternative drug should be early made to avoid
the occurrence of seizures.
- Patients with pre-eclampsia symptoms require seizure prevention. A weekly EEG monitoring
is recommended throughout the two months before delivery. The appearance of EEG
changes as delta rhythm (fig.1) suggests to start Magnesium or Phenytoin therapy. (tab.4)
- The development of seizures does not seem to be related to patients blood pressure.
These prophylactic measures should be added to vitamin K administration 3-4 weeks before
delivery to reduce the incidence of neonatal hemorrhage
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> 10 mmol/l :
cardiac arrest
treatment
CaCL2 10 % 5 - 10
ml iv , O2 with a
mask
Seizure control
Phenytoin
2ff IV (5mins) 200-400mg
(aurantin 150mg/f) Therapeutical 10-
20mg/l
crosses placenta-
5-10mg
Hydralazine Hypertension neonatal
increments
hypotension.
Labetelol 1 mg/kg Hypertension no neonatal effects
no evidence of fetal
0.25-0.5
Nitroprusside Hypertension cyanide
ug/kg/Min.
accumulation
40-120
Nifedipine Hypertension less fetal distress
mg/gtt./nasal
4. Treatment
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The anesthesiologist is involved in the treatment of epileptic symptoms at delivery and rarely
deals with epileptic patients during pregnancy. The seizure presentation is more complex in
pre-eclampsia or HELLP-syndrome, as cesarean section and seizures treatment are
simultaneously present as problems to face [7]. The anesthesiologist has to give anesthesia
to a pregnant woman just reaching the hospital on succeeding tonic-clonic attacks. In these
conditions patients present a high anesthetic risk. General anesthesia is not always
recommended: the propofol administration to stop the attacks can be followed by spinal
anesthesia.
When the epileptic patient is well controlled by therapy during pregnancy, it is not usually
necessary a special treatment at the delivery. However it is possible that the anesthesiologist
is asked to treat epileptic symptoms occurring during labor. If no convulsions are present, a
continuous epidural anesthesia throughout labor is preferred. This technique decreases
seizure occurrence because 1) it suppresses labor pain, 2) maintains a constant anesthetic
plasma concentration producing an anticonvulsant effect. It is important to do not overdosing
local anesthetics: bupivacaine 0.25%, 6ml/hour should be indicated.
- For patients in advanced labor or near delivery propofol administration (1% 3-4ml in
repeatable bolus) should be attempted. If this treatment is effective, the woman may have a
normal delivery or a low forcep application with an acceptable level of consciousness. After
delivery diazepam 10mg should be given.
- For cesarean delivery it is possible to control seizures by propofol and decide about general
or spinal anesthesia after evaluating fetal conditions. In our experience good results are
achieved by spinal anesthesia (see Tab.5). During surgery a propofol infusion at rate 10-15
ml/h is administered. After delivery diazepam 10 mg is usually given. Other drugs other than
their routine therapy are not necessary by using this protocol. In any case thiopental and
general anesthesia may also be used with good results, the most known approach, the best
one. An effective support is done by Magnesium administration (see Tab.4).
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This group is usually represented by patients suffering from eclampsia or the related
syndrome, as the HELLP syndrome. The treatment is similar to that for seizure occurrence
(more frequently in eclampsia than in HELLP), that is prompt delivery. However, in eclampsia
syndrome there is a severe hypertension while in HELLP syndrome there are clotting
abnormalities.
4.2.1 Seizure treatment in eclamptic patient
Convulsions are only a part of this severe syndrome, due to the severe hemodynamic
impairment: blood pressure is often over 200mmHg . In Tab.4 the therapeutic procedures are
described . If it is possible, seizure treatment should include prophylactic magnesium or
phenytoin because both the drugs are able to stabilize an epileptic patient. However the acute
treatment is based on the use of propofol or thiopental as diazepam produces neonatal
hypotonia and respiratory depression and cannot be used, except after delivery. The
antihypertensive therapy is very important: the drug of choice is hydralazine or, in alternative,
labetelol and nitroprusside. Good results are achieved by nifedipine nasal drops [8]. This
procedure is of value in an unconscious patient without a venous line. The effect is constant
and the dosage ranges 20-80mg . The choice of the anesthesiological technique depends on
anesthesiologist experience (see tab.5). During the general anesthesia EEG monitoring is
suggested; if the monitoring system does not have any EEG module, an
electroencephalograph should be used for the EEG recording that to detect an eventual
perioperative status epilepticus. This practice requires specific knowledge. In fact it is difficult
to make diagnosis of seizures on curarized patient and the sparing use of hypnotic drugs may
be ineffective in switching off a epileptic focus. Skilled professionals should be immediately
available to look after the newborn. In his absence the anesthetist has to start neonatal
resuscitation and to decide newborn ICU admission. As regards as postoperative treatment,
convulsions are prevalent on general anesthesia awakening : diazepam should be given after
the delivery and repeated one hour after. The neurologic status has to be carefully assessed.
If an hour after the end of the anesthesia the patient is still unconscious, cerebral edema
should be suspected and a brain TC scan and patient admission in ICU should be planned
(fig.1)
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In the HELLP syndrome typical severe clotting abnormality and related bleeding, are the most
important findings. Therefore a central venous line, large amounts of blood, plasma and
platelets should be available before cesarean section. To gain a central access , a long
catheter from an antecubital vein should be advanced to reach the atrium, as significant
venous bleeding is frequently observed. Hemothorax by subclavian vein and important neck
and thight hematoma by jugular or femoral attempts are the most troublesome complications.
In these patients there is a high incidence of myocardial infarction and brain haemorrhage.
A brain TC scan is necessary in all patients suffering from HELLP syndrome and seizures.
General anesthesia is the technique of choice for cesarean section because clotting
abnormalities contraindicate the regional anesthesia. Caution has to be used for intubation to
avoid oropharyngeal bleeding. Postoperative management should be careful in the evaluation
of hepatic and coagulation function. Patients suffering from severe forms have to be admitted
in ICU (fig.2)
figure 2
Tab.5 guidelines for cesarean section in the eclampsia related syndrome
Mild Pre-eclampsia Severe Pre-eclampsia HELLP
Routine monitors
(ECG,non invasive Routine monitors +
Routine monitors + plus
blood pressure, pulse plus an arterial line,
an arterial line, central
oximeter, central venous or
Monitoring venous (control the
(capnography or pulmonary artery
coagulation tests) +
transcutaneus PCO2 in catheter+ EEG
EEG monitoring
regional anesthesia), monitoring
stethoscope
Whitacre or Sprotte
needle, Bupivacaine
1% hyperbaric
General anesthesia if
General anesthesia if
Spinal anesthesia 10-15mg according to seizure. seizure or clotting
height: < 150 cm 8mg, abnormality.
> 150 cm 10mg, > 160
cm 12mg, > 180 cm
15mg.L1-2 level
Specially Indicated
after a epidural
analgesia labor..10 ml General anesthesia if
General anesthesia if
Epidural anesthesia of plan Bupivacaine seizure or clotting
seizure.
0.5% to have analgesia abnormality.
for surgery. Risk of not
completed analgesia
General anesthesia Clear antacid, metoclopramide IV.Left or right uterine displacement,
pre-oxygenate at least 3-4 min.
Or
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Epileptic pregnant women have to be carefully evaluated and a polytherapy should be
changed in a monotherapy to avoid toxic fetal effects. The occurrence of seizures in non
epileptic patients should suggest an eclamptic syndrome. In this case the delivery is the
treatment more effective for seizures. Drugs of choice in seizures therapy are magnesium,
propofol, thiopental and phenytoin.
References
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visitors n.
http://anestit.unipa.it/OBSTE/EPILING.HTM
If you have epilepsy it doesn’t automatically mean that having a family will be any more
difficult for you than for anyone else. But it might mean that as a parent-to-be you have more
things to consider before, during and after the pregnancy. These pages look at the
issues around pregnancy and parenting that sometimes affect people with epilepsy. It aims to
help you look at how these issues might relate to your epilepsy.
Having epilepsy doesn’t usually make it harder to have a family – but it might mean that you
have more things to consider when starting to try for a family.
Some people with epilepsy feel that their sexual response or sex drive is low which may make
it difficult for a couple to “get pregnant”. This can happen for a number of different reasons;
anxiety, depression,
and the side effects of some anti-epileptic drugs (AEDs) may all contribute. If you are
concerned about your sex drive or sexual response you can ask your doctor for advice.
Certain AEDs may reduce the production of sperm for some men, which could reduce a
man’s fertility. Some women with epilepsy have irregular periods or a condition called
Polycystic Ovary Syndrome. These can be side effects of some AEDs. Both these side
effects are treatable but can make becoming
pregnant more difficult.
More information on polycystic ovary syndrome is on the women and epilepsy page
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Although you may be concerned that AEDs might affect your chances of becoming pregnant it
is important never to stop taking AEDs suddenly and without the medical guidance of your
neurologist or GP.
Sometimes epilepsy happens as part of an inherited medical condition, passed from parent to
child. This is rare, but includes the conditions neurofibromatosis and tuberous sclerosis.
Genetics play a part in the development of epilepsy in everyone, but how important this is
varies. As every situation is different, it can be helpful to talk about this with a doctor who
specialises in genetics (geneticist).
Information on different types of seizures
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During pregnancy your body uses up more of your AEDs than usual. This means the amount
of AEDs you normally take may not be enough to stop your seizures from happening.
Your neurologist might ask you to have a blood test to make sure that the amount of AEDs
you take is at the right level for you and your baby. Testing the levels of the AED in your blood
helps your neurologist decide
if the dose needs to be changed. Testing blood levels works for some AEDs but not all. With
all AEDs, the frequency of seizures will be watched to see if the dose of the drug needs to be
increased. If it does need to be increased, the dose will usually be slowly
reduced to its original level after the birth.
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If the baby’s father has epilepsy, his epilepsy and any AEDs he takes will not affect the baby’s
development, because the baby will not come into contact with his AEDs.
For a woman with epilepsy who takes AEDs during her pregnancy, her baby will be exposed
to the AEDs in the womb. Although while she is pregnant a mother’s bloodstream is kept
separate from her unborn baby’s, some substances can pass from her
blood into her baby’s blood via the placenta. These substances include nutrients, oxygen,
antibiotics, alcohol and medication, including AEDs. Some AEDs can affect how the baby
grows and develops in the womb, particularly so in the first 15 weeks of pregnancy when the
baby’s main organs and skeleton are developing.
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For any pregnant woman there is a small risk (a ‘background’ risk) that her baby may be born
with a birth defect. Birth defects, or developmental abnormalities as they are sometimes
called, are physical problems that happen when the development of a baby is affected while it
is in the womb.
There are different types of birth defects, which can affect different organs in the body, and
happen for different reasons. Sometimes birth defects are classed as minor and major. Minor
malformations are those that do not require surgery, and major malformations are those that
do need surgery to correct them.
Major birth defects include cleft lip, cleft palate and problems with the development of the
spine and nervous system (called neural tube defects). Other defects include problems with
how the internal organs (such as the heart and lungs) develop. Sometimes
the child’s arms, legs, or the way their face looks, may also be affected.
If you are pregnant, avoiding alcohol, smoking and other drugs will help minimise the risk of
birth defects.
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If For a woman with epilepsy taking AEDs during her pregnancy, the risk of a birth defect to
her baby is slightly increased above the background risk. How much the risk increases
depends on which AEDs are being taken and at what dose.
Different AEDs vary in the risk they pose; and the risk is often greater the higher the dose of
the drug. At the moment sodium valproate (Epilim) appears to have greater risks than other
AEDs. An ongoing study into the effects and risks of AEDs on an unborn baby’s
development aims to help understand those risks and to find out whether any specific drugs
should be avoided during pregnancy.
However it is worth remembering that about 95% (95 in 100) of pregnant women with
epilepsy have a perfectly normal pregnancy and a healthy baby with no malformations.
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Preconception counselling
Because of the possible effects of AEDs on an unborn baby, having your AEDs reviewed
before you get pregnant can help you and your neurologist to make sure that you are taking
the most appropriate AED and at the most suitable dose during your pregnancy.
Preconception counselling is an opportunity for you and your doctor to consider any changes
to your epilepsy treatment that might be helpful before you
become pregnant. It helps you to be fully informed about the effects pregnancy may have on
your epilepsy, as well as the effect your epilepsy and AEDs may have on your pregnancy and
unborn baby.
If you have seizures you are likely to be advised to keep taking your AEDs throughout your
pregnancy. However your doctor may suggest taking the lowest possible dose that will still
control your seizures. Or they might suggest a change to the AEDs that you take.
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Some women prefer not to take AEDs during their pregnancy and may want to discuss this
option with their neurologist. If you have seizures during pregnancy there is a risk of injury to
yourself and your baby. This risk could be higher (depending on the type
and frequency of seizures you have) than the risk of the AED affecting your baby.
If you have been seizure-free for two or three years, your doctor might suggest slowly
stopping your AEDs before starting your family. However there is a risk if your AEDs are
stopped that your seizures could start
again. Having seizures again could affect your lifestyle - for example your home or work life -
and if you are currently driving you would need to hand your driving licence in until you were
seizure-free for one year.
Making decisions about your medication is not always easy and preconception counselling
should give you the chance to ask any specific questions or talk about any concerns you may
have.
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Pre-natal screening is the name for a number of different checks that are done during
pregnancy to see how the baby is developing in the womb. This includes ultrasound scans
which are done at certain intervals
throughout the pregnancy. As part of the pre-natal screening checks, some women have their
alpha-fetoprotein (AFP) levels checked in a blood test at around 15-16 weeks into their
pregnancy. AFP is a type of protein which is passed from an unborn baby to its mother. The
levels of AFP in a mother’s blood can indicate the risk of their baby being born with certain
health disorders including spina bifida. Screening does not say for certain if a baby will be
born with or without any birth defects or developmental abnormalities. It just uses the
information collected to determine the risk of an unborn baby being born with birth defects or
developmental abnormalities.
Vitamin K plays an important part in making our blood thicken (clot). A very small number of
newborn babies (about 0.01% or 1 in 10,000) are born without enough vitamin K. This can
cause nose bleeds, mouth bleeds
and in some cases internal bleeding. The risk of having low vitamin K is slightly higher for
babies whose mothers have taken certain AEDs during their pregnancy.
The Department of Health recommends that all newborn babies are given extra vitamin K at
birth or within the first month of being born. Depending which AEDs you take you may also be
prescribed a daily 10mg dose of vitamin K during the last month of your pregnancy, as well as
your baby being given vitamin K at birth (usually by injection).
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Most women with epilepsy have normal deliveries and healthy children. It is useful for the
midwife and medical team who will be at the birth to know about your epilepsy, including what
type of seizures you have, which AEDs you take (if any) and when you normally take them.
Ideally, AEDs are taken as normal during labour.
If you want to have a home birth you will need to carefully consider the possible effects of
having a seizure during labour, which could lead to complications. Women who would like to
have a water birth may also need to consider the effect of seizures if they become confused
or lose awareness during their seizures. Generally, caesarean sections are
only necessary if this is in the best interests of the mother and her baby.
About 1 - 2% (1 in 100 to 1 in 50) of women with epilepsy have a tonic clonic seizure during
labour - even if they don’t normally have tonic clonic seizures. If a seizure happens during
labour, drugs can usually be given to control it. A further 1 - 2% (1 in 100 to 1 in 50) will have
a tonic clonic seizure up to 24 hours after the birth.
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It is helpful to tell the midwife and medical team if your seizures have any particular triggers.
For example if pain, tiredness or over-breathing have triggered seizures in the past.
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If you have epilepsy and are thinking of becoming pregnant, or you are already pregnant, you
might like to contact the UKEPR. The UKEPR is a long-term study looking at the effect of
AEDs on unborn babies and the effect of having seizures while pregnant. The study lets you
speak to an epilepsy nurse and ask questions about your pregnancy and epilepsy.
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Childcare
If you or your partner’s seizures are controlled then epilepsy may not affect how you look after
your child. However, parents who still have seizures may find taking extra safety measures
helpful. This depends on the type of seizures the person has and the activity involved.
Breastfeeding is recommended even if you take AEDs. Your baby will have become used to
the drugs while in your womb, and only a small amount of AEDs
is in breast milk. Some drugs (for example phenobarbital) can make a baby over sleepy, so it
may be a good idea to alternate between formula and breastfeeds. Patient information
leaflets, which come with each new prescription of an AED, often include
information about breastfeeding for that particular drug. If you have any doubts, talking this
through with your neurologist, midwife, or health visitor may help.
If you’re more likely to have seizures when you’re over tired, you may want to consider if
breastfeeding your baby during the night is a good option for you. If possible, sharing night
time feeds with a partner might
be one way to increase the chance of a good night’s sleep.
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• Dressing and changing your baby on the floor means they only have a short fall if you
have a seizure.
• Sponging your baby down on a changing mat on the floor is safer than bathing the
baby in water.
• When carrying your baby it may be safer to use a carrycot or sling than to carry them
in your arms. A padded carrycot will help protect your baby if you have a seizure.
• Putting a deadlock on your baby’s pram means the pram will stay in place if you let
go of it during a seizure.
• When feeding your baby, a lower highchair is less likely to tip over than a taller one.
• Feeding your baby while you sit on the floor, surrounded by cushions and leaning
against the wall may help to make your baby safer if you suddenly have a seizure.
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Some people wear medical jewellery or carry an ID card saying that they have epilepsy and
what to do if a seizure happens. Even if children are too young to manage seizures, they may
be able to let other people know about the card or jewellery.
Free identity cards are available from the NSE online shop
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If you are concerned about any vaccination your child may need, you can talk about this with
your child’s doctor or paediatrician. It is your choice whether
your child is vaccinated, and having more information might help you make that choice.The
following guidelines are taken from the Department of Health publication ‘Immunisation
against Infectious Disease’.
They state that:
“No child should be denied immunisation without serious thought as to the consequences,
both for the individual child and for the community. Where there
is doubt, advice should be sought from a Consultant Paediatrician, District (Health Board)
Immunisation Co-ordinator, or Consultant in Communicable Disease
Control”.
Immunisation Against Infectious Disease 2006 - "The Green Book" (opens new window)
http://www.epilepsynse.org.uk/pages/info/leaflets/preg.cfm